If hired, can you provide proof of your eligibility to be employed in the United States?*

Yes

No

Are you 18 years of age, or older?*

Yes

No

Have you ever been convicted of ANY crime? (conviction will not necessarily disqualify applicant from employment)*

Yes

No

Disclose ALL misdemeanors and felonies (including Driving Under the Influence (DUI), Minor in Possession (MIP) but you may exclude minor traffic violations)

NOTE: Omitting information or failure to disclose may disqualify you from consideration.

If yes, please explain

EDUCATION AND TRAINING

Name and Location of School

Degree/Certificate Earned

Graduation Date

Date Format: MM slash DD slash YYYY

Major and Minor Fields of Study

Dates Attended

Date Format: MM slash DD slash YYYY

PROFESSIONAL LICENSES AND/OR CERTIFICATIONS

Profession

State Issued

License Number

Has your professional license (in any state) ever been on probation, suspended, revoked, or limited in any way?

Yes

No

If yes, give reason

Please list any relevant certifications

Provide expiration dates, i.e. BLS, ACLS, CCRN:

Date Format: MM slash DD slash YYYY

EMPLOYMENT RECORD

List your present or most recent employer FIRST. Include U.S. Armed Forces experience.Account for ALL the time during the past 7 years including period of unemployment. Include any unpaid work experience. (Attach additional pages as needed.) Omit reasons for leaving if for reasons of health or disability. Resumes are acceptable but may NOT be substituted for the following information

Employer

Full Time

Part Time

Employed From

Date Format: MM slash DD slash YYYY

Employed To

Date Format: MM slash DD slash YYYY

Job Title

Primary Duties/Responsibilities

Manager

Phone #

Reason for leaving

Salary Start

Salary End

May we contact employer?

Yes

No

If no, why:

Employer

Full Time

Part Time

Employed From

Date Format: MM slash DD slash YYYY

Employed To

Date Format: MM slash DD slash YYYY

Job Title

Primary Duties/Responsibilities

Manager

Phone #

Reason for leaving

Salary Start

Salary End

May we contact employer?

Yes

No

If no, why:

Employer

Full Time

Part Time

Employed From

Date Format: MM slash DD slash YYYY

Employed To

Date Format: MM slash DD slash YYYY

Job Title

Primary Duties/Responsibilities

Manager

Phone #

Reason for leaving

Salary Start

Salary End

May we contact employer?

Yes

No

If no, why:

Employer

Full Time

Part Time

Employed From

Date Format: MM slash DD slash YYYY

Employed To

Date Format: MM slash DD slash YYYY

Job Title

Primary Duties/Responsibilities

Manager

Phone #

Reason for leaving

Salary Start

Salary End

May we contact employer?

Yes

No

If no, why:

Employer

Full Time

Part Time

Employed From

Date Format: MM slash DD slash YYYY

Employed To

Date Format: MM slash DD slash YYYY

If no, why:

Job Title

Primary Duties/Responsibilities

Manager

Phone #

Reason for leaving

Salary Start

Salary End

May we contact employer?

Yes

No

If no, why:

Employer

Full Time

Part Time

Employed From

Date Format: MM slash DD slash YYYY

Employed To

Date Format: MM slash DD slash YYYY

Job Title

Primary Duties/Responsibilities

Manager

Phone #

Reason for leaving

Salary Start

Salary End

May we contact employer?

Yes

No

If no, why:

Please list any skills and abilities you wish to be considered. Include skills with equipment or machines you operate, special computer knowledge, laboratory techniques, foreign languages etc

PROFESSIONAL REFERENCES

Please provide information for three work related references that we may contact. Please do not include relatives.

Name, Job Title*

Telephone # in which they can be reached at*

Relationship (Co-Worker/Supervisor)

Name, Job Title*

Telephone # in which they can be reached at*

Relationship (Co-Worker/Supervisor)

Name, Job Title*

Telephone # in which they can be reached at*

Relationship (Co-Worker/Supervisor)

HOW WERE YOU REFERRED TO COMMUNITY MEDICAL CENTER

Employee referral

Walk – In

School

Workforce Development

CMC Website

Newspaper

Other

Name of employee

EMPLOYMENT AGREEMENT
Please read the following carefully before signing this application form. Community Medical Center, Inc. reserves the right to reject any application which has not been fully completed.

I certify the information contained in this application for employment is true to the best of my knowledge and belief. I understand that any omission of facts or misrepresentation is cause for denial of employment and/or dismissal (if hired) regardless of when discovered.

I grant permission for the authorities of Community Medical Center to investigate my work references and release them and any former employer from any and all liability resulting from such investigation. Upon my termination, I authorize the release of reference information on my work.

I agree to submit to a post-offer physical, including drug and/or alcohol screening and recognize employment is contingent upon successfully meeting physical requirements.

I further agree that if I’ve been convicted of a crime, the authorities of Community Medical Center may obtain details of my conviction to determine its relationship to the position I’m applying for as a condition of my employment.

In consideration of my employment, I agree to conform to the rules and regulations of Community Medical Center. My employment may be terminated, with or without cause, at any time, at the option of Community Medical Center or myself.

I understand that Community Medical Center operates 24 hours a day, seven days a week, and that weekend work, holidays, or changes of shift may be required during my employment.

Community Medical Center is tabacco-free. Tobacco use is prohibited on all CMC property.

In accordance with the Drug-Free Workplace Act of 1988it is the policy of Community Medical Center to provide a safe environment for patients, employees and visitors. The illegal manufacture, possession, distribution or use of controlled substances by employees in the workplace is prohibited.

In accordance with Federal law and U.S. Department of Agriculture policy, CMC is prohibited from discriminating on the basis of race, color, national origin, sex, religion, age, disability or marital or family status. We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, disability, marital or veteran status, or any other legally protected status.

Printed Name

eSignature

Date

Date Format: MM slash DD slash YYYY

Community Medical Center
Standards of Behavior

CMC employees believe that through teamwork, we can achieve better results than we could produce as individuals. We are truly committed to excellence, therefore we must help each other adhere to these Standards of Behavior as we continue to grow and learn in order to provide outcomes that exceed our customer’s expectations.

Treat everyone as if he or she is the most important person in our facility. Acknowledge everyone as I pass him or her in the hallway.

Choose a sincerely good attitude by smiling, being friendly and courteous, and using good manners.

Demonstrate and accept personal responsibility for the success of the organization.

Refrain from making excuses or placing blame. Take personal ownership and welcome feedback/suggestions.

Talk with my co-workers in a thoughtful, discrete and respectful manner if I have a grievance or concern.

Deal with issues/concerns by going directly to the person or people involved.

Sincerely apologize and seek remedies when expectations are not met.

Escort anyone who is lost or find someone who can assist.

Help to maintain a quiet, calming and professional environment, keeping noise level in and around patient care areas and hallways to a minimum.

Maintain and respect patient privacy and modesty.

Keep our environment clean and free of clutter, picking up trash in and around the campus.

Inform patients and family members of wait times and provide periodic updates.

Be aware of and respectful to the cultural diversity within our customer population.

Refrain from negative gossip and understand that rudeness and offensive language are never acceptable.

Refrain from unnecessary discussions about personal and work related issues in the presence of customers.

Respect each other’s time by arriving on time for shifts, meetings and appointments.

Accept responsibility for my role at CMC and my department. To do so, I will regularly attend required meetings and will read hospital communication tools, including bulletin boards, newsletters, policies and procedures.

Show willingness to look beyond my assigned task and help others without being asked.

Respond to email, voice mail and other requests in a timely manner, considering an alternate means of communication if there have been three or more messages exchanged in an attempt to reach a conclusion.

Look for ways to meet a request without saying ‘I don’t know’ or ‘It’s not my job’.

Refrain from using negative terms such as ‘Having a bad day’, ‘We’re short-staffed’, and ‘That’s not my patient’ OR ‘I’m too busy’ or any others that may be pertinent to your department.

Take pride in my appearance, adhering to professional conduct code and wearing my badge at all times.

Mentor new employees and welcome them to our team.

Hold each other accountable in a respectful manner for meeting our standards of behavior.

I have read and understand the Community Medical Center Standards of Behavior. I recognize that every job is a self portrait of the person who does it. With this in mind, I pledge to practice these standards daily and to make these standards of performance my standards as a team member of Community Medical Center.